HHS Public Access Author manuscript Author Manuscript
Circulation. Author manuscript; available in PMC 2017 September 20. Published in final edited form as: Circulation. 2016 September 20; 134(12): e236–e255. doi:10.1161/CIR.0000000000000441.
Cardiovascular Health Promotion in Children: Challenges and Opportunities for 2020 and Beyond: A Scientific Statement for Healthcare Professionals from the American Heart Association
Author Manuscript
Julia Steinberger, MD, MS, FAHA Chair, Stephen R. Daniels, MD, PhD, FAHA, Nancy Hagberg, RN, MS, FNP, FAHA, Carmen Isasi, MD, PhD, FAHA, Aaron S. Kelly, PhD, FAHA, Donald Lloyd-Jones, MD, ScM, FACC, FAHA, Russell R. Pate, PhD, Charlotte Pratt, PhD, RD, FAHA, Christina M. Shay, PhD, FAHA, Jeffrey A. Towbin, MD, FAHA, FACC, FAAP, Elaine Urbina, MD, MS, FAHA, Linda V. Van Horn, PhD, RD, FAHA, and Justin P. Zachariah, MD, MPH on behalf of the American Heart Association Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, Council on Functional Genomics and Translational Biology, and the Stroke Council
Abstract
Author Manuscript
This document provides a pediatric-focused companion to the American Heart Association (AHA) Strategic Impact Goal Through 2020 and Beyond, focused on cardiovascular (CV) health promotion and disease reduction in adults and children. The principles detailed in the document reflect the AHA’s new dynamic and proactive goal to promote CV health throughout the lifecourse. The primary focus is on adult CV health and disease prevention, but critical to achievement of this goal is maintenance of ideal CV health from birth through childhood to young adulthood and beyond.
Author Manuscript
Emphasis is placed on the fundamental principles and metrics that define CV health in children for the clinical or research setting and a balanced and critical appraisal of the strengths and weaknesses of the CV health construct in children and adolescents are provided. Specifically, it discusses two important factors: 1) the promotion of ideal CV health in all children, and 2) the improvement of CV health metric scores in children currently classified as having “poor” or “intermediate” CV health. Other topics include the current status of CV health in U.S. children, opportunities for the refinement of health metrics, improvement of health metric scores, and possibilities for promoting ideal CV health. Importantly, concerns about the suitability of using single thresholds to identify elevated CV risk throughout the childhood years and the limits of our current knowledge are noted, while providing suggestions for future directions and research.
Background The American Heart Association (AHA) Strategic Impact Goal Through 2020 and Beyond statement, published in 2010, provides guidance on cardiovascular (CV) health promotion and disease reduction in adults and children.1 It also offers a novel definition of CV health and identifies metrics to enable CV health monitoring in the pediatric and adult populations over time. The principles detailed in the document reflect the AHA’s new dynamic and proactive goal to promote CV health throughout the lifecourse. The primary focus is on
Steinberger et al.
Page 2
Author Manuscript
adult CV health and disease prevention, but critical to achievement of this goal is maintenance of ideal CV health from birth through childhood to young adulthood and beyond.
Author Manuscript
This paper provides a pediatric-focused companion document emphasizing the fundamental principles and metrics that define CV health in children for the clinical or research setting. The authors offer a balanced and critical appraisal of the strengths and weaknesses of the CV health construct in children and adolescents and will discuss two important factors: 1) the promotion of ideal CV health in all children, and 2) the improvement of CV health metric scores in children currently classified as having “poor” or “intermediate” CV health. Other topics include the current status of CV health in U.S. children, opportunities for the refinement of health metrics, improvement of health metric scores, and possibilities for promoting ideal CV health. Concerns about the suitability of using single thresholds to identify elevated CV risk throughout the childhood years and the limits of our current knowledge will be noted, while providing suggestions for future directions and research.
Author Manuscript
Despite a comprehensive definition of CV health, it is now widely recognized that the development of childhood CV and metabolic disease risk factors, and the consequent loss of CV health, accelerate in childhood primarily in conjunction with weight gain and obesity.2–9 The number of overweight children (defined as a BMI of ≥ 85th percentile using the Centers for Disease Control and Prevention (CDC) growth charts) and the prevalence of obesity (defined as a BMI of ≥ 95th percentile using the CDC growth charts) have risen dramatically over the last four decades for youth from 2 to 19 years of age,10,11 with a recognized epidemic occurring between the mid-1980s and mid-1990s in the U.S.11,12 U.S. data from 2009–2010 indicate that 17% of 2 to 19 year-olds are obese, and an additional 15% are overweight.13,14 Youth with obesity have significantly worse circulating lipid profiles (higher total and low-density lipoprotein (LDL) cholesterol, higher triglycerides, and lower high-density lipoprotein (HDL) cholesterol), higher blood pressure (BP), glucose, and insulin concentrations than their non-obese peers.3,7–9,15 Obesity in youth is also linked to increased left ventricular (LV) mass in childhood16,17 and adulthood,18 as well as increased carotid intima-media thickness measured in adulthood.19–24 Although obesity prevalence has plateaued in the last decade, the rates in minority, low income, and rural populations remain high.25 Moreover, rates of pediatric severe obesity are increasing and the prevalence is approximately 6% in the U.S.26 Youth with severe obesity are at much higher risk of developing CV disease even compared to overweight or obese peers.27
Author Manuscript
There is also evidence that childhood levels of CV risk factors predict early subclinical atherosclerosis and cardiac pathology28,29, adult morbidity and mortality.30,31 The Bogalusa Heart Study demonstrated that in youth who died at an average age of 19.6 years, there was a direct association between degree of atherosclerosis in the coronary arteries and levels of ante-mortem CV risk factors, including BMI, lipids, and BP.28 The Pathobiologic Determinants of Atherosclerosis in Youth (PDAY) Study, which included autopsies of nearly 3,000 individuals aged 15–34, provided similar results in post-mortem examination to the Bogalusa Heart Study findings.29
Circulation. Author manuscript; available in PMC 2017 September 20.
Steinberger et al.
Page 3
Author Manuscript Author Manuscript
The stages of CV disease prevention include primordial (the prevention of risk factor development), primary (the prevention of CV disease and stroke among individuals at risk), and secondary (the prevention of recurrent disease and complications). Most children are born with ideal CV health, which is defined by the AHA as the simultaneous presence of four favorable health behaviors (related to smoking, body mass index, physical activity, and healthy diet status) and three favorable health factors (total cholesterol, blood pressure, and fasting blood glucose levels) (Table 1).1 Unfortunately, over time most children experience a decline in health factors and behaviors resulting in loss of ideal CV health as they reach adulthood. Since it is well known that it is difficult to achieve sustained lifestyle changes in adults, and risk factor control through the use of medication cannot fully restore the low risk state present in ideal CV health, maintaining better levels of CV health through childhood is a desirable goal.1 The advancement and sustainability of the AHA’s goal (“By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%”)1 directly hinges upon promoting ideal health behaviors for the maintenance (or improvement of non-ideal) health factors in children and adolescents. The collective goal of pediatric healthcare providers and researchers—and for society as a whole should be to understand how ideal health behaviors and health factors are lost, and how this decline might be prevented.
Author Manuscript
For the pediatric population, the following AHA health behavior criteria are suggested in AHA’s definition of CV health: abstinence from smoking, a body-mass index (BMI) < 85th percentile, sixty minutes or more of moderate/vigorous physical activity daily, and adherence to a diet emphasizing fruits, vegetables, fish, whole grains, low sodium and few sugar-laden foods and drinks. AHA recommended health factor metrics for ideal CV health in children are as follows: total cholesterol < 170 mg/dL, blood pressure (BP) < 90th percentile, and a fasting plasma glucose level of < 100 mg/dL.1 Although the authors recognize BMI could more objectively be viewed as a health factor, for purposes of agreement with the AHA Strategic Impact Goal Statement, in this document we have maintained its classification as a behavior. The issue of BMI classification merits further consideration in future definitions.
Author Manuscript
Although “normal” levels for childhood CV health factors have been defined using population-based distributions, definitions for elevated or “high risk” levels have been based on clinical expert consensus32–37 due to the lack of long-term data relating elevated childhood CV risk factor levels to adult CV endpoints. Significant developmental changes during maturation are likely to reduce the strength of the associations between CV risk factors measured in childhood and adult CV risk factors and outcomes; for example, fluctuations in CV risk factor levels during puberty are well known.38–41 The International Childhood Cardiovascular Cohort (i3C) Consortium data indicate that current childhood risk thresholds for lipids have low sensitivity and specificity for identifying elevated lipid classification in adulthood.42–45 The use of cross-sectional population-based cut-points for defining risk in childhood can contribute to significant risk misclassification later in life. Thus, longitudinal data tracking CV health metrics from very early in life through maturation and linking these to adult CV health metrics is essential for establishing improved surveillance tools.
Circulation. Author manuscript; available in PMC 2017 September 20.
Steinberger et al.
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Author Manuscript
Refinement of the CV Health Metrics
Author Manuscript
In the AHA Strategic Impact Goal Statement pediatric cut-points defining ideal CV health were provided as a first step toward improving primordial prevention of CVD.1 Some of these cut-points are imperfect and pose challenges to accurately identifying the “at risk” child. These cut points are less than optimal because they are based on percentiles from general populations rather than on relations to outcomes. The values were chosen to coincide with definitions used in current guidelines, and are available in NHANES. Nevertheless, such metrics will aid in the assessment of educational and preventive programs, provide data about improvements in health behaviors (i.e. as healthy diets and physical activity), and for reporting on declines in prevalence of smoking, overweight and obesity, and improvement in values for total cholesterol, blood pressure, and presence of elevated fasting blood glucose.46 Clearly, many aspects of ideal CV health are challenging to define and measure; the sections below offer perspectives on the challenges for addressing specific CV health factors. Smoking
Author Manuscript
In the AHA Strategic Impact Goal Statement, the ideal metric for smoking behavior is defined for youth 12 to 19 years of age as “Never tried; never smoked a whole cigarette”. Determination of smoking habits, particularly in children and adolescents, is challenging. Questionnaires may underestimate the true smoking rate due to perceived loss of confidentiality when parents or others are present,47 however the Centers for Disease Control Data may circumvent some of these limitations.48 Assessment is also affected by factors such as varying definitions of smoking, fear of reprisal, or desire to inflate one’s status in the eyes of others. To successfully estimate smoking behavior in pediatric populations, objective measurement techniques can be used (e.g., cotinine levels) to estimate second-hand smoke exposure, light smoking, and heavy smoking. Availability to evaluate such assessments in pediatric populations is particularly pertinent since approximately 4.8 million U.S. children younger than 12 years are exposed to secondhand smoke in their homes. Furthermore, a report on neurobehavioral disorders in children exposed to second-hand smoke has shown a two-fold increase in prevalence compared to those not exposed to second-hand smoke in their homes.49 Although cotinine levels are available in many population-based investigations, including in a subset of participants in NHANES, exposure to second-hand smoke was not included as a primary CV health metric in the AHA Strategic Impact Goal Statement due to insufficient evidence linking secondhand smoke exposure to adverse CV health among youth.
Author Manuscript
The growing numbers of youth that have used electronic cigarettes or “e-cigarettes” is also notably increasing50. This is particularly concerning for the CV health of US children and adolescents because the use of e-cigarettes is associated with increased intention to smoke cigarettes among those who never smoked conventional cigarettes.50,51 E-cigarette use was also not listed as a primary CV health metric in the AHA Strategic Impact Goal Statement due to insufficient data available to evaluate its contribution to adverse CV health.
Circulation. Author manuscript; available in PMC 2017 September 20.
Steinberger et al.
Page 5
Body Mass Index
Author Manuscript Author Manuscript
BMI is the most widely used measure of weight status in public health surveillance and in epidemiological research in children and adolescents. In large, diverse groups BMI is well correlated with adiposity (i.e., body composition). BMI is widely used to screen children and adolescents for overweight and obesity and is an easy-to-calculate metric. The Centers for Disease Control and Prevention (CDC) Growth Charts provide sex-specific BMI-for-age growth curves for children aged 2 to 20 years.52 Using these charts, normal weight status is defined as an age/sex-specific BMI < 85th percentile. Overweight is defined as an age/sexspecific BMI ≥ 85th and < 95th percentile. Obesity is defined as an age/sex-specific BMI ≥ 95th percentile.34 The criterion set for ideal CV health is a BMI < 85th percentile. The recommended method for determining BMI is to objectively measure height and weight, calculate BMI as kg/m2, and either plot BMI on the CDC growth chart52 or use statistical analysis software to calculate the age/sex-specific BMI percentile. BMI is the most widely used measure of weight status in public health surveillance and in epidemiological research in children and adolescents. While BMI is highly correlated with adiposity,52 it is not an ideal measure of fatness (i.e., percent body fat) in children and adolescents.53,54 It is known that variability in lean weight is a source of error in estimates of adiposity that are based on BMI.54,55 A criterion measure of adiposity is provided by dual-energy x-ray absorptiometry (DXA), which provides highly reliable estimates of lean mass, fat mass and percent body fat.56,57 Further, skinfold thicknesses58 and bioelectrical impedance59 have been widely used to estimate percent body fat in research studies. Healthy Diet
Author Manuscript
Healthy dietary behaviors directly influence multiple CV risk factors such as obesity, dyslipidemia, hypertension, and hyperglycemia. Two of the primary features of healthy eating include diet quality and energy balance; the latter is defined as caloric consumption matched with energy expenditure. Unfortunately, compared to the other six ideal health behaviors/factors categories, children in the United States score most poorly in regard to a healthy diet. Approximately 91% of U.S. children are classified as having a “poor” diet score, 9% are classified as “intermediate,” and
Circulation. Author manuscript; available in PMC 2017 September 20. Published in final edited form as: Circulation. 2016 September 20; 134(12): e236–e255. doi:10.1161/CIR.0000000000000441.
Cardiovascular Health Promotion in Children: Challenges and Opportunities for 2020 and Beyond: A Scientific Statement for Healthcare Professionals from the American Heart Association
Author Manuscript
Julia Steinberger, MD, MS, FAHA Chair, Stephen R. Daniels, MD, PhD, FAHA, Nancy Hagberg, RN, MS, FNP, FAHA, Carmen Isasi, MD, PhD, FAHA, Aaron S. Kelly, PhD, FAHA, Donald Lloyd-Jones, MD, ScM, FACC, FAHA, Russell R. Pate, PhD, Charlotte Pratt, PhD, RD, FAHA, Christina M. Shay, PhD, FAHA, Jeffrey A. Towbin, MD, FAHA, FACC, FAAP, Elaine Urbina, MD, MS, FAHA, Linda V. Van Horn, PhD, RD, FAHA, and Justin P. Zachariah, MD, MPH on behalf of the American Heart Association Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, Council on Functional Genomics and Translational Biology, and the Stroke Council
Abstract
Author Manuscript
This document provides a pediatric-focused companion to the American Heart Association (AHA) Strategic Impact Goal Through 2020 and Beyond, focused on cardiovascular (CV) health promotion and disease reduction in adults and children. The principles detailed in the document reflect the AHA’s new dynamic and proactive goal to promote CV health throughout the lifecourse. The primary focus is on adult CV health and disease prevention, but critical to achievement of this goal is maintenance of ideal CV health from birth through childhood to young adulthood and beyond.
Author Manuscript
Emphasis is placed on the fundamental principles and metrics that define CV health in children for the clinical or research setting and a balanced and critical appraisal of the strengths and weaknesses of the CV health construct in children and adolescents are provided. Specifically, it discusses two important factors: 1) the promotion of ideal CV health in all children, and 2) the improvement of CV health metric scores in children currently classified as having “poor” or “intermediate” CV health. Other topics include the current status of CV health in U.S. children, opportunities for the refinement of health metrics, improvement of health metric scores, and possibilities for promoting ideal CV health. Importantly, concerns about the suitability of using single thresholds to identify elevated CV risk throughout the childhood years and the limits of our current knowledge are noted, while providing suggestions for future directions and research.
Background The American Heart Association (AHA) Strategic Impact Goal Through 2020 and Beyond statement, published in 2010, provides guidance on cardiovascular (CV) health promotion and disease reduction in adults and children.1 It also offers a novel definition of CV health and identifies metrics to enable CV health monitoring in the pediatric and adult populations over time. The principles detailed in the document reflect the AHA’s new dynamic and proactive goal to promote CV health throughout the lifecourse. The primary focus is on
Steinberger et al.
Page 2
Author Manuscript
adult CV health and disease prevention, but critical to achievement of this goal is maintenance of ideal CV health from birth through childhood to young adulthood and beyond.
Author Manuscript
This paper provides a pediatric-focused companion document emphasizing the fundamental principles and metrics that define CV health in children for the clinical or research setting. The authors offer a balanced and critical appraisal of the strengths and weaknesses of the CV health construct in children and adolescents and will discuss two important factors: 1) the promotion of ideal CV health in all children, and 2) the improvement of CV health metric scores in children currently classified as having “poor” or “intermediate” CV health. Other topics include the current status of CV health in U.S. children, opportunities for the refinement of health metrics, improvement of health metric scores, and possibilities for promoting ideal CV health. Concerns about the suitability of using single thresholds to identify elevated CV risk throughout the childhood years and the limits of our current knowledge will be noted, while providing suggestions for future directions and research.
Author Manuscript
Despite a comprehensive definition of CV health, it is now widely recognized that the development of childhood CV and metabolic disease risk factors, and the consequent loss of CV health, accelerate in childhood primarily in conjunction with weight gain and obesity.2–9 The number of overweight children (defined as a BMI of ≥ 85th percentile using the Centers for Disease Control and Prevention (CDC) growth charts) and the prevalence of obesity (defined as a BMI of ≥ 95th percentile using the CDC growth charts) have risen dramatically over the last four decades for youth from 2 to 19 years of age,10,11 with a recognized epidemic occurring between the mid-1980s and mid-1990s in the U.S.11,12 U.S. data from 2009–2010 indicate that 17% of 2 to 19 year-olds are obese, and an additional 15% are overweight.13,14 Youth with obesity have significantly worse circulating lipid profiles (higher total and low-density lipoprotein (LDL) cholesterol, higher triglycerides, and lower high-density lipoprotein (HDL) cholesterol), higher blood pressure (BP), glucose, and insulin concentrations than their non-obese peers.3,7–9,15 Obesity in youth is also linked to increased left ventricular (LV) mass in childhood16,17 and adulthood,18 as well as increased carotid intima-media thickness measured in adulthood.19–24 Although obesity prevalence has plateaued in the last decade, the rates in minority, low income, and rural populations remain high.25 Moreover, rates of pediatric severe obesity are increasing and the prevalence is approximately 6% in the U.S.26 Youth with severe obesity are at much higher risk of developing CV disease even compared to overweight or obese peers.27
Author Manuscript
There is also evidence that childhood levels of CV risk factors predict early subclinical atherosclerosis and cardiac pathology28,29, adult morbidity and mortality.30,31 The Bogalusa Heart Study demonstrated that in youth who died at an average age of 19.6 years, there was a direct association between degree of atherosclerosis in the coronary arteries and levels of ante-mortem CV risk factors, including BMI, lipids, and BP.28 The Pathobiologic Determinants of Atherosclerosis in Youth (PDAY) Study, which included autopsies of nearly 3,000 individuals aged 15–34, provided similar results in post-mortem examination to the Bogalusa Heart Study findings.29
Circulation. Author manuscript; available in PMC 2017 September 20.
Steinberger et al.
Page 3
Author Manuscript Author Manuscript
The stages of CV disease prevention include primordial (the prevention of risk factor development), primary (the prevention of CV disease and stroke among individuals at risk), and secondary (the prevention of recurrent disease and complications). Most children are born with ideal CV health, which is defined by the AHA as the simultaneous presence of four favorable health behaviors (related to smoking, body mass index, physical activity, and healthy diet status) and three favorable health factors (total cholesterol, blood pressure, and fasting blood glucose levels) (Table 1).1 Unfortunately, over time most children experience a decline in health factors and behaviors resulting in loss of ideal CV health as they reach adulthood. Since it is well known that it is difficult to achieve sustained lifestyle changes in adults, and risk factor control through the use of medication cannot fully restore the low risk state present in ideal CV health, maintaining better levels of CV health through childhood is a desirable goal.1 The advancement and sustainability of the AHA’s goal (“By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%”)1 directly hinges upon promoting ideal health behaviors for the maintenance (or improvement of non-ideal) health factors in children and adolescents. The collective goal of pediatric healthcare providers and researchers—and for society as a whole should be to understand how ideal health behaviors and health factors are lost, and how this decline might be prevented.
Author Manuscript
For the pediatric population, the following AHA health behavior criteria are suggested in AHA’s definition of CV health: abstinence from smoking, a body-mass index (BMI) < 85th percentile, sixty minutes or more of moderate/vigorous physical activity daily, and adherence to a diet emphasizing fruits, vegetables, fish, whole grains, low sodium and few sugar-laden foods and drinks. AHA recommended health factor metrics for ideal CV health in children are as follows: total cholesterol < 170 mg/dL, blood pressure (BP) < 90th percentile, and a fasting plasma glucose level of < 100 mg/dL.1 Although the authors recognize BMI could more objectively be viewed as a health factor, for purposes of agreement with the AHA Strategic Impact Goal Statement, in this document we have maintained its classification as a behavior. The issue of BMI classification merits further consideration in future definitions.
Author Manuscript
Although “normal” levels for childhood CV health factors have been defined using population-based distributions, definitions for elevated or “high risk” levels have been based on clinical expert consensus32–37 due to the lack of long-term data relating elevated childhood CV risk factor levels to adult CV endpoints. Significant developmental changes during maturation are likely to reduce the strength of the associations between CV risk factors measured in childhood and adult CV risk factors and outcomes; for example, fluctuations in CV risk factor levels during puberty are well known.38–41 The International Childhood Cardiovascular Cohort (i3C) Consortium data indicate that current childhood risk thresholds for lipids have low sensitivity and specificity for identifying elevated lipid classification in adulthood.42–45 The use of cross-sectional population-based cut-points for defining risk in childhood can contribute to significant risk misclassification later in life. Thus, longitudinal data tracking CV health metrics from very early in life through maturation and linking these to adult CV health metrics is essential for establishing improved surveillance tools.
Circulation. Author manuscript; available in PMC 2017 September 20.
Steinberger et al.
Page 4
Author Manuscript
Refinement of the CV Health Metrics
Author Manuscript
In the AHA Strategic Impact Goal Statement pediatric cut-points defining ideal CV health were provided as a first step toward improving primordial prevention of CVD.1 Some of these cut-points are imperfect and pose challenges to accurately identifying the “at risk” child. These cut points are less than optimal because they are based on percentiles from general populations rather than on relations to outcomes. The values were chosen to coincide with definitions used in current guidelines, and are available in NHANES. Nevertheless, such metrics will aid in the assessment of educational and preventive programs, provide data about improvements in health behaviors (i.e. as healthy diets and physical activity), and for reporting on declines in prevalence of smoking, overweight and obesity, and improvement in values for total cholesterol, blood pressure, and presence of elevated fasting blood glucose.46 Clearly, many aspects of ideal CV health are challenging to define and measure; the sections below offer perspectives on the challenges for addressing specific CV health factors. Smoking
Author Manuscript
In the AHA Strategic Impact Goal Statement, the ideal metric for smoking behavior is defined for youth 12 to 19 years of age as “Never tried; never smoked a whole cigarette”. Determination of smoking habits, particularly in children and adolescents, is challenging. Questionnaires may underestimate the true smoking rate due to perceived loss of confidentiality when parents or others are present,47 however the Centers for Disease Control Data may circumvent some of these limitations.48 Assessment is also affected by factors such as varying definitions of smoking, fear of reprisal, or desire to inflate one’s status in the eyes of others. To successfully estimate smoking behavior in pediatric populations, objective measurement techniques can be used (e.g., cotinine levels) to estimate second-hand smoke exposure, light smoking, and heavy smoking. Availability to evaluate such assessments in pediatric populations is particularly pertinent since approximately 4.8 million U.S. children younger than 12 years are exposed to secondhand smoke in their homes. Furthermore, a report on neurobehavioral disorders in children exposed to second-hand smoke has shown a two-fold increase in prevalence compared to those not exposed to second-hand smoke in their homes.49 Although cotinine levels are available in many population-based investigations, including in a subset of participants in NHANES, exposure to second-hand smoke was not included as a primary CV health metric in the AHA Strategic Impact Goal Statement due to insufficient evidence linking secondhand smoke exposure to adverse CV health among youth.
Author Manuscript
The growing numbers of youth that have used electronic cigarettes or “e-cigarettes” is also notably increasing50. This is particularly concerning for the CV health of US children and adolescents because the use of e-cigarettes is associated with increased intention to smoke cigarettes among those who never smoked conventional cigarettes.50,51 E-cigarette use was also not listed as a primary CV health metric in the AHA Strategic Impact Goal Statement due to insufficient data available to evaluate its contribution to adverse CV health.
Circulation. Author manuscript; available in PMC 2017 September 20.
Steinberger et al.
Page 5
Body Mass Index
Author Manuscript Author Manuscript
BMI is the most widely used measure of weight status in public health surveillance and in epidemiological research in children and adolescents. In large, diverse groups BMI is well correlated with adiposity (i.e., body composition). BMI is widely used to screen children and adolescents for overweight and obesity and is an easy-to-calculate metric. The Centers for Disease Control and Prevention (CDC) Growth Charts provide sex-specific BMI-for-age growth curves for children aged 2 to 20 years.52 Using these charts, normal weight status is defined as an age/sex-specific BMI < 85th percentile. Overweight is defined as an age/sexspecific BMI ≥ 85th and < 95th percentile. Obesity is defined as an age/sex-specific BMI ≥ 95th percentile.34 The criterion set for ideal CV health is a BMI < 85th percentile. The recommended method for determining BMI is to objectively measure height and weight, calculate BMI as kg/m2, and either plot BMI on the CDC growth chart52 or use statistical analysis software to calculate the age/sex-specific BMI percentile. BMI is the most widely used measure of weight status in public health surveillance and in epidemiological research in children and adolescents. While BMI is highly correlated with adiposity,52 it is not an ideal measure of fatness (i.e., percent body fat) in children and adolescents.53,54 It is known that variability in lean weight is a source of error in estimates of adiposity that are based on BMI.54,55 A criterion measure of adiposity is provided by dual-energy x-ray absorptiometry (DXA), which provides highly reliable estimates of lean mass, fat mass and percent body fat.56,57 Further, skinfold thicknesses58 and bioelectrical impedance59 have been widely used to estimate percent body fat in research studies. Healthy Diet
Author Manuscript
Healthy dietary behaviors directly influence multiple CV risk factors such as obesity, dyslipidemia, hypertension, and hyperglycemia. Two of the primary features of healthy eating include diet quality and energy balance; the latter is defined as caloric consumption matched with energy expenditure. Unfortunately, compared to the other six ideal health behaviors/factors categories, children in the United States score most poorly in regard to a healthy diet. Approximately 91% of U.S. children are classified as having a “poor” diet score, 9% are classified as “intermediate,” and
